Case Report Endovascular Aortoiliac Reconstruction to Allow Excision of an Infected Axillobifemoral Bypass Thomas A. Heafner, Michael Clemens, Daniel Scott, Yiming Ching, Sean Hislop, and Zachary M. Arthurs, San Antonio, Texas

Axillofemoral graft reconstructions were initially intended to restore lower extremity perfusion in high-risk patients with symptomatic aortoiliac atherosclerotic occlusive disease. However, these reconstructions are now relegated to ‘‘bailout’’ procedures for infected grafts or high-risk critical limb ischemia patients that fail endovascular therapy. Infection of an extra-anatomic bypass graft is a challenging complication as it occurs in poor operative candidates with limited revascularization options and failure has a high rate of amputation and mortality. Described is a novel approach using endovascular reconstruction to treat symptomatic Trans-Atlantic Inter-Society Consensus-II type D aortoiliac lesions allowing for complete excision of an infected axillobifemoral bypass.

Axillofemoral graft reconstructions were historically intended to provide lower extremity revascularization in patients with aortoiliac disease who were at high risk for an intra-abdominal aortic reconstruction. They have been increasingly used as a means of providing extra-anatomic lower extremity revascularization after excision of infected intra-abdominal vascular pathology. Since initial technical descriptions, the complications of the axillary-to-femoral bypass graft have been well documented. These include graft dissociation, graft thrombosis, and graft stenosis, all contributing to technique changes in graft placement. However, the infected axillofemoral graft poses a formidable challenge for surgeons. Few publications exist documenting the morbidity, mortality, and

Department of Vascular Surgery, San Antonio Military Medical Center, San Antonio, TX. Correspondence to: Thomas Heafner, MD, Department of Vascular Surgery, San Antonio Military Medical Center, 3851 Roger Brooke Dr, San Antonio, TX 78234, USA; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2014.03.009 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: February 4, 2014; manuscript accepted: March 7, 2014; published online: ---.

surgical challenges of treating this complication. Described is a novel approach using an endovascular reconstruction to treat symptomatic Trans-Atlantic Inter-Society Consensus-II (TASC) type D aortoiliac lesions allowing for complete excision of an infected axillofemoral bypass.

CASE REPORT Thirty days after an axillobifemoral bypass procedure for claudication performed at an outside facility, a 70-yearold male with multiple prior intra-abdominal operations was bending over a sink, began bleeding from his right flank and subsequently fell to the floor. He presented to our emergency department tachycardic and hypotensive with paramedics controlling the bleeding with external compression. In addition, he had sensory loss at the level of the mid-calf. He was taken emergently to the operating room where the axillobifemoral graft was found to be constructed in a lazy-Y configuration with inline flow from the right axillary artery to the left common femoral artery (CFA) using a 7-mm ringed polytetrafluorethylene (PTFE) graft and a 6-mm ringed PTFE jump graft to the right CFA (Fig. 1). On exposure, the anastomosis at the level of the jump graft was completely dehisced from the bypass graft, friable, surrounded by biofilm, and without incorporation 1

2 Case Report

Fig. 1. Axillobifemoral bypass in a lazy-Y configuration with inline flow from the right axillary artery to the left CFA using a 7-mm ringed PTFE graft and a 6-mm ringed PTFE jump graft to the right CFA. into the surrounding tissues, consistent with a graft infection. However, the infection appeared limited to this segment with good tissue incorporation proximally and distally. As the patient had poor collateralization to his lower extremities evident by the development of Rutherford IIa ischemia of his right leg, a damage control procedure was performed. This consisted of graft debridement 4 cm proximal and distal; this segment was replaced with 6mm PTFE graft. Before reperfusion, distal thrombectomies were performed, and a completion angiogram confirmed restoration of flow to bilateral CFAs with brisk filling of the profunda arteries. Postoperatively, the patient had resolution of his lower extremity ischemia and return of biphasic signals to his bilateral lower extremities. As preoperative planning for complete graft excision was being made, he was maintained on intravenous (I.V.) vancomycin and Zosyn. On review of his computed tomography angiogram, the patient had a concomitant 3.5-cm infrarenal aortic aneurysm with bilateral complete iliac occlusions to the level of both femoral arteries with significant circumferential calcification and intraluminal thrombus (Fig. 2). In considering our revascularization options, an open aortobifemoral procedure would be challenging because of his prior intra-abdominal operations, and a left-sided axillobifemoral bypass could introduce cross-contamination through the abdominal subcutaneous tracts. With no evidence of infection in the groins,

Annals of Vascular Surgery

Fig. 2. Preoperative coronal image demonstrating a 3.5-cm infrarenal aneurysm with bilateral common iliac occlusion. an endovascular reconstruction was determined to have the lowest risk of causing a superimposed infection. Given these were long segment aortoiliac occlusions, covered stents as opposed to uncovered were chosen because of concerns about the ability to obtain an adequate intraluminal diameter, decrease the chance of thrombus embolization, and provide the longest durability. Surgery was delayed for 10 days while waiting for culture results. Tissue and graft cultures failed to identify an offending organism suggesting a likely Staphylococcus epidermidus infection. Additionally, 2 sets of blood and urine cultures were also negative. Bilateral femoral artery cutdowns and a local debridement of both groins were performed without any evidence of infection. Using a combined left brachial and bilateral femoral artery access, his aortoiliac occlusions were crossed subintimally with wires. True-lumen was confirmed at the level of the infrarenal aorta. First, an Endologix (Irvine, CA) 28  70  16  30 mm unibody prosthesis was deployed at the aortic bifurcation. An Endologix 20  28  75 mm suprarenal aortic extension was placed below the renal arteries to exclude the small aneurysm. Bilaterally, CookeZenith ZSLE (Bloomington, IN) 13  90 mm extension limbs were deployed from the new aortic bifurcation to the level of the inguinal ligament. A 33-mm Coda balloon (Bloomington, IN) was used to occlude the distal aorta while the iliac limbs were ballooned to a profile of 11 mm, purposely rupturing the

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Case Report 3

DISCUSSION

Fig. 3. Postoperative image after endovascular reconstruction. An Endologix unibody with suprarenal extension was used to reconstruct the bifurcation and exclude the aneurysm. Bilaterally, CookeZenith ZSLE extension limbs were deployed to the level of the inguinal ligament. native vessels to provide greater flow (Fig. 3). Bilaterally, 10-mm rifampin-soaked Dacron grafts were then sewn to the end of the ZSLE limbs, and the distal anastomosis was spatulated onto the profunda femoris. The prior axillobifemoral bypass graft was then explanted to the level of the anterior superior iliac spine. Both groin anastomoses were covered with sartorius muscle flaps with wound vacuum-assisted closure. At the completion of the case, the patient had biphasic Doppler signals in the dorsalis pedis and posterior tibial arteries bilaterally and was neurologically intact. The following week, using the previous infraclavicular incision, the right axillary artery was isolated and the anastomosis was transected revealing a heavy calcified native axillary artery. An endarterectomy was performed and closed with a saphenous vein patch and a local muscle flap. The remaining infected bypass graft and capsule were completely excised. The patient was maintained on broad-spectrum I.V. antibiotics while in the hospital and was transitioned to lifetime suppressive oral Bactrim therapy on discharge. At his 3-month evaluation, duplex examination showed normal aortic stent velocities without evidence of endoleak or stenosis. He is able to ambulate without claudication symptoms.

Blaisdell and Hall first described axillofemoral reconstructions in 1963 to treat lower extremity claudication and critical limb ischemia in high-risk patients with aortoiliac disease.1 The original technique used a lazy-S configuration from the ipsilateral axillary artery to the CFA. Since then, several graft modifications, as in our patient, have been used to revascularize bilateral lower extremities. Although short-term patency appeared promising, the primary patency at 5 years was only 30e75%, making them an inadequate long-term solution to lower extremity claudication.2 These bypasses have now found a niche for reperfusing the lower extremities in patients with infected aortic grafts and high physiologic risk critical limb ischemia patients that fail endovascular therapy. As extra-anatomic bypasses are generally considered ‘‘bailout’’ procedures, graft infections in this setting are associated with significant morbidity and mortality. Most of the time, the infection starts in the groin and progresses proximally along the graft. Our case was unique in that the groins were uninvolved, and the infection was limited to jump-graft anastomosis in the subcutaneous tissues of the abdomen. Previous reports noted an above-theknee amputation rate of 25e44% and operative mortality of 18e22%, which are dependent on the indication for the operation (tissue loss versus claudication versus infected aortic graft)3,4. Open prosthetic reconstructive options include axilloprofunda, axillopopliteal, and obturator bypasses in unaffected tissue planes, whereas autologous reconstruction could be placed in the groin. These options all require tunneling new grafts through the abdominal subcutaneous tissues, and it would be challenging to avoid the previous tracts. An endovascular approach utilizing the uninvolved groins avoids potential cross-contamination from the subcutaneous tissues. A majority of aortoiliac atherosclerotic occlusive disease patterns are now amenable to endovascular procedures. Angioplasty with uncovered stents are standard for short segment TASC-II types A and B lesions with a 10-year assisted patency rate of 71%; however, their 2-year primary and secondary patency rates are significantly lower ranging from 69% to 76% and 85% to 95%, respectively, for TASC-II types C and D lesions.5 On the other hand, covered stent repair of TASC-II types C and D lesions have a primary and primary-assisted patency of 70% and 88% at 1-year and 80% and 95% at 5 years.5 This is comparable to the 5-year patency rate of an open aortobifemoral reconstruction at 95% without

4 Case Report

the associated morbidity and mortality of a major operation.6 Our patient had TASC-II type D lesions amenable to endovascular repair. We chose an Endologix unibody because of its low-profile (17Fr and 8Fr) and ability to reconstruct the aortic bifurcation while excluding the aneurysm. We chose CookeZenith limbs to extend to the inguinal ligament because the Dacron fabric is easy to construct the iliofemoral anastomosis. As concomitant femoral artery disease is a significant predictor of stent-graft failure,5 bilateral outflow procedures were constructed to improve patency. Any reconstruction with prosthetic material for an existing infection is at risk for a recurrent graft infection. While the incidence of endograft infection is w0.2% after clean procedures, the incidence after placement in a contaminated procedure is unknown.7 The risk of infection is highest in the first 4 weeks after implantation as a pseudointimal lining forms over the luminal surface; however, it has been reported to occur several years after implantation.8 Therefore, suppressive antibiotic therapy is recommended to prevent graft seeding from the transient bacteremia that occurs after an infection (urinary tract/pneumonia) or after routine procedures (i.e., repeat endovascular, colonoscopy, dental work).9 Only small case series have reported on the management of endograft infections, but the consensus recommends following the same dictum for open repairs of complete graft excision. In conclusion, axillofemoral bypass graft infections present a formidable challenge with few good reconstructive options. We present the use of endoaortoiliac reconstruction for limb salvage in this patient.

Annals of Vascular Surgery

Authorship: Study conception and design was performed by T.H., Y.C., S.H., and Z.M.A. Study analysis and interpretation was done by M.C. and D.S. Data collection was performed by T.H., M.C., and S.H. The article was written by T.H. and M.C. Critical revision of the article was performed by M.C., D.S., Y.C., and S.H. Final approval of the article was performed by all the authors. Authors’ Note: The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army, Department of the Air Force, Navy Department, or Department of Defense. REFERENCES 1. Blaisedell FW, Hall AD. Axillary-femoral Artery Bypass for Lower Extremity Ischemia. Surgery 1963;54:563. 2. Schneider J. Extra-Anatomic Bypass. In: Saunders ed. Rutherford’s Vascular Surgery. Philadelphia: Elsevier, 2005. pp 1633e52. 3. De Virgilio C, Cherry KJ, Gloviczki P, et al. Infected lower extremity extra-anatomic bypass grafts: management of a serious complication in high-risk patients. Ann Vasc Surg 1995;9:459e66. 4. Marston W, Risley G, Criado E, et al. Management of failed and infected axillofemoral grafts. J Vasc Surg 1994;20:357e65. 5. Powell R, Rzucidio E. Aortoiliac disease: endovascular treatment. In: Saunders ed. Rutherford’s Vascular Surgery. Philadelphia: Elsevier, 2005. pp 1667e81. 6. Menard M, Belkin M. Aortoiliac disease: direct reconstruction. In: Saunders ed. Rutherford’s Vascular Surgery. Philadelphia: Elsevier, 2005. pp 1613e32. 7. Blanch M, Berj on J, Vila R, et al. The management of aortic stent-graft infection: endograft removal versus conservative treatment. Ann Vasc Surg 2010;24:554.e1e5. 8. Chiesa R, Astore D, Frigerio S, et al. Vascular prosthetic graft infection: epidemiology, bacteriology, pathogenesis and treatment. Acta Chir Belg 2002;102:238e47. 9. Back M. Local complications: graft infection. In: Saunders ed. Rutherford’s Vascular Surgery. Philadelphia: Elsevier, 2005. pp 643e62.

Endovascular aortoiliac reconstruction to allow excision of an infected axillobifemoral bypass.

Axillofemoral graft reconstructions were initially intended to restore lower extremity perfusion in high-risk patients with symptomatic aortoiliac ath...
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